Post Primary School Form – Completed By Parent/Guardian


Please fill in all fields marked with an *

* Childs Name:
* Childs Date of Birth:
* Address:
* Parent(s) or Guardian(s) Name:
* Telephone Number(s):
* School:
* Year:
* Course(LC,LCA, PLC etc.):
* Address:
* School Number:
* Name of Principal:
Student Profile:

* Family size:
* Number of Boys:
* Number of Girls:
* Position in family:
* Were there concerns about the student`s early development (e.g. walking, talking)?

* Are there any medical condition/s that might be affecting academic progress? YesNo

If there are, please give details:


Has the student been assessed by any of the following?

* Psychologist: YesNo
Date Assessed:
Outcome:

* Physiotherapist: YesNo
Date Assessed:
Outcome:

* Occupational Therapist: YesNo
Date Assessed:
Outcome:

* Speech and Language Therapist: YesNo
Date Assessed:
Outcome:

* Paediatrician: YesNo
Date Assessed:
Outcome:

* Did the student have a hearing test? YesNo
Outcome:

* Did the student have a sight test? YesNo
Outcome:

* What are the student`s main strengths:
* What are the student`s main interests and hobbies:
* What are the main challenges facing the student:
* What measures/resources could be put in place to help him/her overcome these challenges:
Consent

I/ We consent to a psychological evaluation of my/our son/daughter by Edward Joyce, Psychologist.

* Name of Student:
Name of both Parents or Legal Guardians: All persons who have legal custody of the child.

* Father/Legal Guardian:
* Mother/Legal Guardian:
* Date:
Please enter the letters below and then click on the send button.
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